American College of Physicians: Internal Medicine — Doctors for Adults ®

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Thursday, January 21, 2010

Patient-Driven Primary Care Shouldn't be Labeled "Concierge"

This post by Alan Dappen, MD, appeared originally at Better Health.

I bristle when my patient-driven, fee-for-service primary practice, DocTalker Family Medicine, gets lumped into the "concierge" movement, as it frequently does. First, veterinarians, accountants, mechanics lawyers and all other service providers in everyday life who work directly for their clients and not as "preferred providers" for the insurance companies are not labeled "concierge." Secondly, the label "concierge" implies exclusivity, membership, high yearly retainers, and capped patient enrollment. Each of these labels we too reject.

A practice like ours out-competes the traditional model and the "concierge idea" in almost every measurable way: access, convenience, patient control, speed to treatment, quality and finally and maybe most importantly for the sake of the health care debate, price. Our boss is each patient, one at a time, and our goal is to provide the most cost effective delivery model achievable. We strive for nothing less than making primary care immediate, high quality, patient-controlled and affordable to every American. We deliver a concierge-level service at a price that is much less than even the price-fixing controlled by the insurance-driven model to date.

Click on the "More" link to continue this post.

Central to our philosophy is how we approach payment. What we sell is time; we charge purely on time-based services. Prices for materials, like supplies, vaccines, and labs are posted on the website and have little mark-up so that we can pass on the savings to our patients. Everyone who interferes with patient control, causes a conflict of interest, or increases cost has been dismissed from the relationship. This includes insurance companies, Medicare, data-miners, coders and drug reps. Our patients pay when services are rendered, just like any other services purchased in our lives.

We applaud concierge practices for providing VIP-service that all patients deserve: immediate access to a practitioner, convenience, and personalized and high quality care. We offer the same high level of service, but with key differences:

No rationing of care by price. Unlike the concierge philosophy, there is no access fee, which in many concierge practices can total $1,500 per year. We instead sell time. We charge in five-minute increments of time since it's the most transparent and policeable way of measuring our productivity. Our patients have a choice to pay-as-they-go, which means that they pay when service has been rendered, ($33.33 for five minutes) be it a phone call, 10-minute office visit, 10-minute e-mail or 10-minute videoconference, no matter what time of day or day of the year. We do offer a 25% discount to patients who put money in a pre-paid account, which means that patients can pay for service ahead of time, and will use the time when they need it. These pre-paid patients have a discounted rate of $25 for every 5 minutes. Patients can close their accounts with us at any time at no penalty.

The average person needs about an hour of care a year, meaning they have 24-7 instant access to us for $300 per year. Over 50% of interactions are solved through phones and e-mails. About 75% of the patients in our system spend less than $300 in a year. Fewer than 1% of our patients this year (out of an active patient group 3000) spent over $ 1,500 and most of these people are elderly, trapped at home with significant medical problems. We are the only medical practice left in Fairfax and Arlington County, Va. (combined population of 1.3 million) that offers house calls. This gives you an idea of the price difference that we have over the concierge and even the typical business model of care.

No exclusivity or capping of patient numbers. Our philosophy and business model is based on a volume business. We estimate that each medical provider in the practice must carry a work load of about 2,000 active patients to make a competitive living. We do not limit the number of patients we will take. When we need to add on a new primary care physician (PCP) to accommodate new patients, we do. Our satisfaction comes from the mission of providing excellent care at an excellent price and eliminating all conflicts of interest that arise between the doctor and patient that either undermine the relationship or increase the cost of the service.

Helping to solve the primary care crises. PCPs are in short supply. There are not enough of us to go around and more retiring faster than they are being made. Medical schools fail to attract primary care specialists in any large numbers since the field typically promises soul-crushing workloads and frustrations in reimbursement, which rapidly leads to high burnout. One of the directions the burned-out physician heads is towards the concierge model. By most definitions the concierge solution is a solution for the doctor.

The concierge model places a premium price on access to primary care, taking advantage of the shortage of primary care physicians. I predict this is not sustainable. The typical concierge practitioner collects $1 million in access fees from clients and takes care of 600-800 patients, which totals 25-33% of capacity in a typical practice where physicians are expected to care for 2,000 to 2,500 patients. Under the concierge banner, primary care costs three to five times more than needed; it would also require a primary care work force three times larger than it is today.

I understand that our practice seems a little radical, but some call us "the practice of the future." In truth, it's how medicine used to be practiced only a few decades ago. Likewise, or practice embodies the medical home described by many who believe in the key role primary care needs to play in our health care system. To make this happen, we've upgraded phones, emails, video, computers , the electronic medical records and direct communications between patient and doctor into the practice and linked it to time-based billing like most other sectors of the economy.
My partners and I hope that others with the same hopes and goals for primary care will consider this model or something like it soon. The future of primary care depends on it, and doctors are the solution.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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1 Comments:

Anonymous james gault said...

This looks like a workable practice model that provides "old-timey" care in a fee for service reimbursement system.Maybe the anti-fee-for-service critics should look at what fee for service can do when it is separated from the Medicare price controls and the insurance hegemony.

January 21, 2010 at 12:43 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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